Citation Nr: 1802698 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 05-16 421 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to compensation under 38 U.S.C. § 1151 for pancreatitis claimed to be the result of treatment provided by the Department of Veterans Affairs. 2. Entitlement to compensation under 38 U.S.C. § 1151 for diabetes mellitus. 3. Entitlement to compensation under 38 U.S.C. § 1151 for depression. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel INTRODUCTION The appellant served on active duty in the Navy from August 1974 to August 1978. He is the recipient of the Good Conduct Medal. This matter comes before the Board of Veterans' Appeals (Board) from a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Board remanded this matter for further development in January 2011. A Supplemental Statement of the Case (SSOC) was issued in February 2016. A review of the record shows that the RO has substantially complied with all remand instructions. The appellant and his representative have not contended otherwise. Stegall v. West, 11 Vet. App. 268 (1998). The appellant was afforded a hearing before a Decision Review Officer (DRO) in June 2010. A transcript is of record. The appellant was afforded a Board videoconference hearing before a Veterans Law Judge (VLJ) in September 2010. A transcript is of record. In an October 2017 letter, the Board advised the appellant that the VLJ before whom he had testified in September 2010 was no longer employed by the Board. He was offered the opportunity to attend another hearing before the Veterans Law Judge who would decide his claim, but the appellant did not respond. As noted in the October 2017 letter, absent a response from the appellant, the Board will presume that he does not want another hearing and proceed with consideration of his claims based on the evidence of record. FINDINGS OF FACT 1. The record contains no indication that the appellant developed pancreatitis, or any other pancreatic disorder, due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. 2. The record contains no indication that the appellant's diabetes mellitus was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. 3. The record contains no indication that the appellant's depression was due to or aggravated beyond its natural progression by carelessness, negligence, lack of proper skill, error in judgment, or similar instance on fault on the part of VA, or an event not reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for pancreatitis have not been met. 38 U.S.C. §§ 1151, 5107 (2012); 38 C.F.R. § 3.361 (2017). 2. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for diabetes mellitus have not been met. 38 U.S.C. §§ 1151, 5107 (2012); 38 C.F.R. § 3.361 (2017). 3. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for depression have not been met. 38 U.S.C. §§ 1151, 5107 (2012); 38 C.F.R. § 3.361 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) Neither the appellant nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Applicable Law A. Standard of Proof The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." See Gilbert, 1 Vet. App. at 54. B. § 1151 Claims Veterans who sustain an additional disability as the result of VA hospitalization, medical or surgical treatment, vocational rehabilitation, or examination shall receive disability compensation in the same manner as if such disability or death were service connected. 38 U.S.C. § 1151. A disability is a qualifying additional disability if 1) it was not the result of the veteran's willful misconduct and the disability was caused by hospital care, medical or surgical treatment; or examination furnished to the veteran under any law administered by VA, and 2) the proximate cause of the disability was a) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or b) an event not reasonably foreseeable. Id. In determining whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran's condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran's additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c) (1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran's additional disability or death; and 1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or 2) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. 38 C.F.R. § 3.361(d). III. Analysis The appellant contends that the developed pancreatitis, or another pancreatic disorder, as a result of substandard VA medical care. He also contends that he developed diabetes mellitus as a result of such pancreatic disorder and that his depression was permanently aggravated as well. A. Background i. April 2012 VA Medical Opinion A VA medical opinion was obtained in April 2012. The examiner explained that the appellant presented to the emergency room on August 3, 2002, with abdominal pain exacerbated by eating and improved with H2-blockers. The appellant had experienced such pain for at least two years and had been diagnosed at a private emergency room with biliary disease two years prior to presentation at the VA emergency room. He experienced similar attacks every five to six months, which he only treated with H2-blockers. The appellant reported drinking six beers every night and smoking. He was noted to have a 60-pack per year history. The appellant denied any medical illnesses and reported only a biopsy of a benign left mandibular cyst. His temperature was 98.3 degrees. Examination revealed a tender right upper abdomen and was negative for evidence of peritonitis. Lipase was 178 U/L and amylase was 4 U/L, which the examiner stated were normal. However, it was notable that blood alcohol was 1 mg/dL on presentation to the emergency room. Ultrasounds and CT scans were performed. The attending physician observed that the appellant appeared to have acute cholecystitis and a large pancreatic mass, which could not yet be precisely characterized. Neoplasm could not be ruled out. The plan was to admit the appellant and try to treat for acute cholecystitis with IV antibiotics while they worked up the pancreatic mass. If cholecystitis was not improved by antibiotics, an emergency cholecystectomy may be required. The appellant's symptoms progressed with worsening subjective pain; thus, an open cholecystectomy was performed. The pathology was gallbladder, cholecystectomy: acute and chronic cholecystitis, cholelithiasis, and adenomyoma of fundus; and portions of cyst wall and contents, lesion from head of pancreas: lymphoepithelial cyst. The examiner observed that the appellant was able to be discharged August 8, 2002, five days later. His first follow-up appointment was August 19, 2002. His temperature was 98.3 degrees. His incision was observed to have been left open to secondary healing. He complained of flatus, but felt good. His wound anterior closure opened up partially but second posterior fascia was intact. The wound looked clean and there was no discharge or evidence of infection. The plan was to return to clinic in two weeks unless more dehiscence of wound was experienced. On August 23, 2002, the appellant returned to the operating room with fevers and abdominal pain. He described low-grade temperature and abdominal pain followed by high temperatures and chills since the morning prior. The examiner observed that the appellant reported that he was still drinking six beers per day. His temperature upon admission was 102.3 degrees. Examination revealed tenderness in the right side of the abdomen with no peritonitis. Lipase was 153 U/L. A CT scan was performed, which revealed an open anterior abdominal wound. Stranding of the fat in the region of the gallbladder fossa in the right upper quadrant was identified, most likely postsurgical changes. There was no focal fluid collection to suggest an abscess. Mild inflammatory stranding was identified in the retrocecal region. Appendicitis could not be ruled out. A known lymphoepithelial cyst in the region of the pancreatic head/body measured 6.6 by 8.5 cm. Such was unchanged. There was no pelvic mass, adenopathy, or abscess. The examiner noted that the appellant was admitted and started on antibiotics and fluids. Conservative measures failed and the appellant developed worsening symptoms. Thus, he was taken to the operating room on August 27, 2002. The pathology was pancreas, partial resection of lesion: connective and adipose tissue with fibrosis, acute, and chronic inflammation and focal foreign body granulomatous response; and pancreas, removal of lesion: lymphoepithelial cyst showing multifocal areas of ulceration with acute and chronic inflammatory response of surrounding tissue plus foreign body granulomatous response to keratinous material, focal abscess formation, and portion of pancreatic tissue showing focal fibrosis and mild chronic inflammation. The appellant had a slow, uneventful recovery and was discharged on September 12, 2002. He returned to the emergency room on September 26, 2002, but left without telling anyone, per the contemporaneous clinical note. The appellant was seen in the surgery clinic the next day. His temperature was 99 degrees. Examination revealed wound left to secondary healing with mesh repair. The wound appeared to be granulating well and had halved in size. He was to return to the clinic in three weeks. The examiner explained that the appellant was later noted to have developed an incision hernia. He was scheduled for repair in late October 2002, but was unable to make it to his appointment due to the "flu." He and his family did not follow up with general surgery. The examiner observed that a December 2003 primary care note states that the appellant was still drinking and "[he did] not want to have a conversation about [his] drinking." The examiner explained that the appellant never had a diagnosed bout of acute pancreatitis in either of his surgical admissions. He also never had elevated amylase or lipase levels. He noted that the appellant may have had pancreatitis in the past due to alcohol abuse or gallstones, however. The examiner explained that the appellant's pancreatic cyst was a true cyst, rather than a pseudocyst. Such cyst may have been congenital or related to prior bouts of pancreatitis. However, pancreatitis generally is causative of pseudocysts rather than true cysts. The examiner opined that, upon review of the case, there was no evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault. The first surgery was performed to treat progression of symptoms. The main surgery was to perform a cholecystectomy. A biopsy was taken to determine whether the pancreatic mass was cancerous. The examiner opined that the care provided to the appellant met the standard of care. The first surgery was performed due to the concern for mass of malignancy, which was, and still is, the accepted standard of care. The cholecystectomy was performed due to progression of symptoms and the failure of conservative measures. The attending surgeon wanted to complete the workup of the pancreatic mass prior to approaching surgery, but was forced to perform such surgery due to patient symptoms. The examiner noted that the cyst was not "drained." Rather, a biopsy and aspiration were performed to evaluate whether such cyst was malignant. This was, and is, acceptable and within the scope of the standard of care. The examiner explained that the second surgery was performed due to infection of the true pancreatic cyst. With respect to depression, the examiner conceded that any medical problem and its subsequent treatment may be associated with or exacerbate depression. However, all of the care provided by VA at issue was within the scope of the standard of care. Further, the examiner observed that the appellant's depression and medical problems were possibly related to, and exacerbated by, his alcohol abuse. The examiner stated that the appellant never had acute pancreatitis in August or September 2002. He never had elevated amylase or lipase. He explained that the most common causes of pancreatitis in the United States are alcohol abuse and gallstones. Pancreatitis typically causes pseudocysts, while true cysts may be congenital or related to other risk factors such as alcohol abuse. The examiner observed that diabetes is prevalent in the United States. The most common associations with diabetes include morbid obesity, diet, lack of exercise, and alcohol abuse. It was noted that the appellant's body mass increased from 26 kg/m2 to 30 kg/m2. While the appellant's obesity may have been associated with his hernia formation due to failure to exercise, the examiner observed that the appellant cancelled his hernia repair surgery. ii. Additional Evidence The Board observes that an August 3, 2002, emergency room note states that the appellant admitted to drinking four to six beers per day and that an August 24, 2002, clinical note states that the clinician observed that the appellant was outside smoking just prior to examination. An August 26, 2002, treatment consent form, signed by the appellant, indicates that he provided express consent for VA clinicians to perform a biopsy of his pancreatic mass. Such consent form noted the possibility of infection. A February 2003 clinical note states that the appellant established care in the VA system in Tuscaloosa. His past history was significant primarily for having been in normal vigorous health until August 2002 when he presented to the Houston VA with abdominal pain. Such pain was found consistent with cholelithiasis. Laparoscopic cholecystectomy was converted to an open cholecystectomy because of an incidental finding of an approximately 6 cm pancreatic lymphoendothelial cyst. He did well for a couple of weeks when he developed a postoperative peritonitis. Such postoperative course was significantly compromised by poor healing of the peritoneal fascia and an unusual adverse reaction to intramuscular Demerol in the right deltoid. The appellant's life was noted to have been completely changed. He had been a vigorous outdoor construction worker and was now basically unable to perform physical work. In a Statements in Support of Claim received in February 2004, the appellant stated that he believed VA was negligent in cutting into his pancreas, which resulted in numerous medical problems. He explained that he initially went to the VA Medical Center in August 2002 after experiencing two days of discomfort, which he had been experiencing for two years prior. He stated that, two weeks after he was discharged for the first time, he presented with a fever of 100 to 100.5 degrees which he had experienced for the past five to six days. The doctor told him not to worry about his fever unless it exceeded 101 degrees, although the appellant noted that such conversation would not be recorded in the medical records. He stated that, one week later, his temperature was 104.3 degrees and he was taken by ambulance to the VA Medical Center and that the EMTs suspected a "septic" condition due to his surgical history. The appellant reported that he was taken to surgery for "pancreatitis," where the cyst was removed. He stated that the source of his infection was e-coli, which had entered the cyst in the open wound from his initial surgery. He stated that the infection was the result of his initial surgery and contended that the VA Medical Center failed to properly monitor him following such surgery, even after he informed them that he had a low-grade fever. He stated that Dr. K.L, the chief of surgery at Ben Taub Hospital, reviewed his case and opined that his abdominal cramps were likely the result of the pancreas surgery and that it was very likely that he would develop diabetes if he did not have it already. A March 2005 Social Security Administration (SSA) fully favorable decision regarding the appellant's disability is of record. It references a March 2004 psychological examination report in which the appellant reported a 60-pound weight gain in the previous 18 months, which he attributed to medical problems. The decision also notes that the appellant had a large keloid scar and ventral hernia from "a poorly performed gallbladder operation." However, a review of the referenced March 2004 psychological examination report indicates that the notation in the SSA decision of "a poorly performed gallbladder operation" is based solely upon the history that the appellant provided to the clinician during such evaluation. A June 2007 letter from clinicians at the Baylor College of Medicine states that the appellant had been a patient since February 2004, when he presented for evaluation of a large subcostal ventral hernia that was the sequalae of a complicated pancreatic infection two years prior. He underwent repair of the hernia defect and reconstruction of the abdominal wall in October 2004. Post-operative hospital course was uneventful. He complained of an abdominal bulge in January 2007 and two faculty surgeons determined that his bioprosthetic had stretched and that there may be small herniations within the repair. The plastic surgery service deferred any intervention, feeling that the operative risk outweighed the potential benefit. A November 2009 VA medical opinion notes that the appellant had reported symptoms similar to those he presented with on August 3, 2002, off and on for two years. He had been evaluated outside the VA medical system and advised to have surgery but had declined. During a December 2009 VA examination for aid and attendance or housebound, the appellant reported that he was first diagnosed with diabetes mellitus in 2003. He was noted to have a history of depression related to bipolar disorder. A May 2010 letter from two physicians at the Baylor College of Medicine states that the appellant had an open cholecystectomy and biopsy of a pancreatic lesion at the VA hospital which was complicated by infected necrotizing pancreatitis. He was treated with pancreatic debridement and the placement of vicryl mesh. The letter also states that the physicians had no reason to believe that, had the appellant undergone hernia repair at a VA facility, the standard of care would be any different. They explained that both their private staff and VA staff have similar training, backgrounds, and expectations. During his June 2010 DRO hearing, the appellant testified he received poor postoperative care following an August 2002 gallbladder removal which revealed a cyst. He contended that the cyst became infected from the open wound left by the gallbladder removal, which gave him pancreatitis. He stated that, when he was seen at the VA Medical Center two weeks after the initial operation, he told the clinician, an intern, that he had temperatures of 99.2, 100.5, and 100.8 degrees and that he would take Tylenol to reduce his fever. He stated that his doctor was not present, although an intern was. He testified that the intern sent him home, but he experienced a temperature of 105 degrees the following Friday. The appellant contended that he experienced a fever for four or five days, which resulted in him being taken by ambulance to the VA Medical Center with a temperature of 104.7 degrees. With respect to diabetes, he testified that the VA never told him he had diabetes, but a private physician in Alabama diagnosed him after experiencing vision problems. He stated that another physician looked at his medical records and told him that his blood sugar was greater than 300 the day he was discharged from the VA hospital, but no one told him about that. He stated that he could not remember the physician's name, although he was local. It is unclear whether the appellant was referring to a VA or private clinician. He and J.S., his sister, contend that he developed diabetes as a result of the VA operating on his pancreas cyst. The appellant also stated that, after his second surgery, a VA clinician gave him a shot in the top of his shoulder and his arm swelled up for a day and was painful. T.H., a friend, testified that he observed the appellant experience severe depression in the three years that they had known each other. T.H. stated that his gallbladder was removed by VA but he received a better quality of care because his post-operative infection cleared up. During his September 2010 Board hearing, the appellant testified that he sought emergency treatment from VA to have his gallbladder removed. Previous problems had been controlled by medication. However, a cyst on the pancreas was discovered. He stated that an emergency open cholestectomy was performed, during which the gallbladder was removed. The appellant stated that he experienced an e-coli infection which contaminated his abdominal cavity. He stated that the e-coli got into his cyst and that he was told his pancreatic cyst was benign. He was then discharged, but was prescribed Oxycodone, a medication which included acetaminophen. He stated that he began taking increased doses based upon the advice of the VA nurse phone service. He stated that, the second week after discharge, he experienced temperatures of 100 to 100.7 degrees and indicated that he took Tylenol to bring down the fever. During a follow-up appointment, the appellant stated that he was experiencing fevers and that taking Tylenol dropped his fevers. He stated that the clinician was a "green" intern who was not "as educated and up to date" due to "lack of training." The clinician told him not to worry if the fever was less than 101 degrees. A week later, the appellant had to be taken to the VA Medical Center by ambulance; and his fever was 104.3 degrees. His cyst was removed. The appellant stated that VA should have known that he would develop an infection as a result of his gallbladder surgery. He stated that, after undergoing hernia surgery with private clinicians, he contacted them to report a 100-degree fever and was told to go to the emergency room to receive antibiotics. He also contended that he developed diabetes as a result of his treatment at VA and that he developed or experienced an aggravation of depression as well. He noted that he had been diagnosed with bipolar disorder and that his father also had it. B. Entitlement to § 1151 Compensation As set forth above, in order to establish entitlement to compensation under 38 U.S.C. § 1151, the evidence must show that 1) the appellant has an additional disability which was caused by VA medical care; and 2) that the proximate cause of such disability was either a) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or b) an event not reasonably foreseeable. In this case, there is no competent medical evidence that the appellant developed pancreatitis or any other disorder, or that any disorder was aggravated beyond the natural progression, as the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part, or an event not reasonably foreseeable. With respect to the claims for pancreatitis and diabetes mellitus, the first criterion has not been met because there is no probative evidence that the appellant developed pancreatitis, diabetes mellitus, or any other disorder as a result of VA medical care. The Board observes that the April 2012 VA examiner conceded that any medical care could be associated with or exacerbate depression. However, merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish causation for purposes of 1151. See 38 C.F.R. § 3.361(c)(1). The second criterion certainly has not been met for the claims of pancreatitis, diabetes mellitus, or depression. The April 2012 VA examiner observed that the appellant was not diagnosed with pancreatitis during either of his surgical admissions and explained that his cyst was not indicative of having had pancreatitis during either such admission. He opined that the treatment provided by VA was properly administered and met the standard of care. As the treatment provided by VA met the standard of care, there was no improperly administered care that could permanently worsen any existing depression. The examiner explained that any medical problem and its subsequent treatment could be associated with or could exacerbate depression; however, in the instant case there was no improper care on the part of VA. Further, the examiner explained that the appellant's depression and other medical problems were possibly related to and exacerbated by his alcohol abuse, noted in the medical evidence of record. Likewise, there was no improperly administered care that could cause diabetes mellitus. The examiner noted that morbid obesity, diet, lack of exercise, and alcohol abuse are most commonly associated with diabetes, and observed that the appellant was obese and that his body mass increased from 26 kg/m2 to 30 kg/m2. As noted above, the VA examiner stated that there was no evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. The April 2012 examiner explained that the care provided met the standard of care. The first surgery was performed due to concerns regarding the mass of malignancy, which was, and still is, the accepted standard of care. The cholecystectomy was performed due to a progression of symptomatology and the failure of conservative measures. Although the attending physician wished to complete the workup of the pancreatic mass prior to surgery, surgery was required due to the appellant's symptoms. The cyst was not "drained"; rather, biopsy and aspiration were performed to determine whether such was malignant. The examiner explained that this was, and still is, the acceptable standard of care. The second surgery was performed due to infection of the pancreatic cyst. The Board finds that this April 2012 VA medical opinion is entitled to great probative weight as it is based upon a thorough review of the claims file, discusses the relevant medical evidence of record, and includes a well-reasoned explanation for the conclusions reached. There is no probative evidence to the contrary. Although the May 2010 letter from the Baylor College of Medicine makes reference to pancreatitis while under VA care, the Board finds that the record is negative for a diagnosis of pancreatitis during August or September 2002. The Board also observes that such May 2010 letter does not state what, if any, medical records were reviewed prior to its composition, or whether such was simply based on the history provided by the appellant. Thus, the May 2010 letter is entitled to minimal probative weight regarding whether the appellant had a diagnosis of pancreatitis. Similarly, the June 2007 letter from the Baylor College of Medicine states that the appellant had a pancreatic infection two years prior, but does not state whether the appellant had pancreatitis or whether the history of pancreatic infection was based upon a review of medical records or simply the history provided by the appellant. However, the May 2010 letter does state that the two surgeons had no reason to believe that, had the appellant undergone hernia repair at a VA facility, the standard of care would be any different. They explained that both their private staff and VA staff have similar training, backgrounds, and expectations. Although entitlement to compensation under 38 U.S.C. § 1151 for an incisional hernia as residuals of surgery was denied in a January 2011 Board decision, the Board finds such explanation is relevant to the instant appeal as it speaks to whether private clinicians consider the standard of care to be lower at VA facilities. The Board has considered the appellant and his witnesses' lay histories of symptomatology throughout the appeal period. They are certainly competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The appellant and the witnesses in this case, however, are not competent to determine the cause of the appellant's symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant and his witnesses in this case, who have not been shown by the evidence of record to have medical training or skills. The Board finds the VA examination report to be of greater probative weight than such lay assertions. Additionally, although the appellant is competent to report a medical diagnosis of pancreatitis, his statements must be weighed against the other evidence of record. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, the April 2012 VA examiner explained the reasons for his medical opinions regarding the quality of VA treatment and based his conclusion that there was no evidence of a diagnosis of pancreatitis upon a thorough review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Therefore, the Board finds that the appellant's reports are entitled to less probative weight than the April 2012 VA opinion, which is well-reasoned and based on a review of the evidence of record. Further, the Board has reviewed the evidence of record and medical records are negative for a diagnosis of pancreatitis in August or September 2002, when the medical treatment at issue occurred. Thus, the probative value of the VA medical opinion is strengthened as it is consistent with the contemporaneous clinical evidence of record. The issue of informed consent was not raised by the appellant, nor is it reasonably raised by the record. As there is no competent medical evidence that the appellant experienced pancreatitis, or any other pancreatic disorder, due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part, compensation under 38 U.S.C. § 1151 is not warranted. Further, the appellant's claims for compensation under 38 U.S.C. § 1151 for diabetes mellitus and depression as a result of pancreatitis, or another pancreatic disorder, must be denied because there was no to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part which caused or aggravated such disorders. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to compensation under 38 U.S.C. § 1151 for pancreatitis as residuals of surgery due to treatment by the Department of Veterans Affairs is denied. Entitlement to compensation under 38 U.S.C. § 1151 for diabetes mellitus is denied. Entitlement to compensation under 38 U.S.C. § 1151 for depression is denied. ______________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs